HomeMy WebLinkAbout23-13967 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-13967 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 12 - 1-- 2023 1510 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
LOGAN AVE N BLOCK NO. e✓ 600
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2064828717 0 7 30
6� LAST NAME OL/VAREZ FIRSTNAME MARY MIDDLE A 1 1 2 31
INITIAL
STREET ❑ 9802 55TH AVE S CITY SEATTLE ST WA ZIP 981185746 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNIT{ON PRESENT MEDICAL TRANSPORTED 3
:NTERLOCKYEs NO INTERLOCK YES NO YES No
8❑ LICENSE# STATE yyq SEX'F MM D Y' 10 — 26 — 1989 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 ATE 14 BGK8842 STATE WA u N# 5J6RW2H5XHL052726
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM To
TRLR. A'RLR. 1 5 33
12 3 5 VIN#j VIN#
FROM TO
VEH.YEAR 2017 MAKE HOND MODEL CR-V STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 9 9 34
DAMAGE YES NO YES[:] NO✓
13❑ REGISTERED OWNER INFO MARYOLIVAREZ980255THAVES SEA WA98118 VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILITY INSURANCE z INSURANCE CO PEMCO CA 1768609 4
LI EFFECT I POLICY# TOPVEHICLE CHARGE 36
LEGALLv res❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT a2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:5024722625
16 a
LAST NAME DENNIS FIRST NAME ASHLEY MIDDLE I j
INITIAL
17❑ STREET ❑', 13735 161ST PL SE CITY' RENTON ST WA ZIP 980596834 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL t—T�RANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I No� YES t l NO❑
11
19 LDI IVEW # STATE WA SEX M M MD D.O.B.B. 11 O6 _ 1961 0 39
HELMET I {NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
21❑ LICENSE I CBW6093 TATe WA VIN# 19XFC1F36HE202787
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR 2017 MAKE HOND MODEL CIVIC STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO ASHLEYDENNIS 13735161STPL SE RENTON WA 98059 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE I PORGY#ECO STATE FARM INS 1892423 F1047E 1GQ
IN EFFECTVEwCLE ❑ ,J� CITATION# CHARGE
LEGALLY YES N
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
J.M/TCHELL 10377 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE32832
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13967
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(LAST FIRST,MIDDLE INITIAL)_
ADDRESS&PHONE#
SEX D.O.B. - -
MMDDYYYY.
PASSENGER❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D D B
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On 12/05/23 1 responded to a 2-vehicle non-injury/blocking collision near the 600 block of Logan Ave
N.
I contacted the driver of unit 2 who told me they were stopped for a traffic in the #1 lane of
southbound Logan Ave N when they were rear-ended by unit 1. The driver did not complain of injury.
The vehicle sustained rear bumper damage but was still drivable.
I contacted the driver of unit 1 who told me they were traveling in the #1 lane of southbound Logan
Ave N when they rear-ended unit 2. The driver was not injured. Her vehicle sustained front-end
damage but was still drivable.
But not for the action of UNIT 1 DRIVER the result would not have happened.
I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J.MITCHELL 12-19-23 09:01 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 12/21/2023 8:06:04 AM
BADGE OR ID# 10377 ORI# WA0171300 TIME POLICE DISPATCHED; 3:10 PM TIME POLICE ARRIVED 3:20 PM
PART I PAGE IT]OF
REPORT NO. EE32832 CASE# ' 23-13967 DATE AND TIME 12/05/23 15:10
OF COLLISION
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